The introduction of telemedicine for children with spina bifida: an unexpected increase in outpatient missed visits
Milan Abbi, BS, Teresa L. Russell, MS, Christina L. Chen, FNP, M. Sohel Rana, MBBS, MPH, Bruce M. Sprague, BS, Christina P. Ho, MD, Hans G. Pohl, MD, Briony K. Varda, MD, MPH.
Children's National Hospital, Washington, DC, USA.
BACKGROUND: Under the pressure of COVID, telemedicine was rapidly adopted as a novel visit modality at our institution in 2020. It was subsequently adopted by our spina bifida program to increase access to care, increase visit convenience and reduce overall visit time. However, providers sensed a higher rate of missed virtual visits for SB. We aimed to evaluate the impact of this new visit modality on missed visit rates adjusting for patient and clinical characteristics. METHODS: We performed a retrospective cohort study of all outpatient clinic visits by children with SB and children presenting for other urologic problems in FY19 and FY21 at our institution, stratifying by visit modality (in-person vs. telemedicine). Baseline patient characteristics (sex, language, insurance, childhood opportunity index [COI]) and markers of clinical severity (SB type, ambulatory status, respiratory adjuncts) were included and compared across the fiscal years. The proportion of missed visits were then calculated and compared across fiscal years stratifying by patient and clinical factors, including visit modality. Factors independently associated with missed visits were elucidated using multivariable regression. As a point of reference, the rate of missed visits for a cohort of non-SB (NSB) children presenting for urologic problems during the same time periods was concomitantly analyzed and compared. RESULTS: A total of 3,953 visits were scheduled for 2,380 children (FY19: 516 SB visits and 1,400 NSB; FY21: 609 SB and 1,428 NSB). In FY21, 38% of SB visits were schedule for telemedicine. The rate of missed visits was significantly greater for SB children in FY21 vs. FY19, greater for SB vs. NSB children, and greater for telemedicine among SB children (all p-values < 0.01; Figure 1). There was no difference for SB vs. NSB in FY19 or NSB in-person vs. NSB telemedicine. After adjusting for patient and clinical factors, missed visits were independently associated with a diagnosis of SB (OR 1.3 [1.1 - 1.7], p < 0.010). Private insurance and higher COI levels were protective (OR 0.4 [0.3 - 0.5], p < 0.001 and OR 0.6 [0.5 - 0.8], p < 0.0001). Telemedicine alone did not have an adjusted association with missed visits, however the interaction between SB and telemedicine did (OR 2.4 (1.5 - 3.9), p < 0.001). In a sub-group analysis of FY21 alone, telemedicine visits were independently associated with missed visits (OR 1.4 [1.1 - 1.8], p = 0.02). CONCLUSIONS: After adjusting for patient and clinical characteristics, missed clinic visits were significantly higher in FY21 compared to FY19. This difference appears to be driven by children with SB missing scheduled telemedicine visits. Other associated factors included a child's insurance type and their COI level - a composite measure for indicators of social determinants of health. 
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